Rolfing® Structural Integration Health Intake Form

• As a client of Structure and Dynamics, I personally accept and agree to pay my balance in full, as my responsibility, to Structure and Dynamics at the time of service
• I acknowledge that there is a 24-hour Cancellation Policy or 48 hours’ notice for Monday appointments. I understand that if I do not cancel 24 hours before my scheduled appointment, or do not show for my appointment, I accept the responsibility of being charged the full amount of the appointment If, for any reason, Structure and Dynamics cannot make it to my scheduled appointment, a complimentary session will be offered.
• I understand Structure and Dynamics provides nontraditional rolfing consultations, therapies, and procedures that may not be covered by any private insurance, Medicaid, nor Medicare. If I choose to submit my a medical bill from Structure and Dynamics to any insurance provider, I may accept any reimbursement from that insurer as a payment to myself directly but do not permit this insurer to set any fee for services provided by Structure and Dynamics.
• I understand that should I not pay for services rendered, I may be responsible for all collection, court, attorney, and legal fees. • I understand that I have the right to request that Structure and Dynamics restrict how protected health information about me is used or disclosed for treatment, payment, or health care operations. I understand that Structure and Dynamics is not required to agree to this restriction. Structure and Dynamics complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

I give my permission for Structure and Dynamics to provide treatment as determined medically necessary. I acknowledge that I will have been given the opportunity to discuss the nature and purpose of the treatment; alternate methods of treatment; and the risks, complications and consequences associated with the administration of rolfing. These risks include but are not limited to: bruising, temporary increase in pain, inflammation, numbness, weakness or paralysis, or spinal headache. I further acknowledge that any questions I have regarding the procedure have been answered to my satisfaction and that I have been further told that any additional questions I may have will be answered. I have read (or have had read to me) the above consent. I fully understand that there is no guarantee of successful treatment has been implied. I understand that I am entitled to a copy of this consent form upon request. My consent authorizes arbitration as a solution for any malpractice claims and waives all court involvement.